Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Anesthesia Management in Intramural Uterine Myoma and Obesity Morbid Patients Who Underwent Myomectomy Perlaparatomy

Introduction. Obesity is a condition that increases the challenges in the surgical process. Obesity increases the risk of sleep apnea and affects anaesthetics. This case report aims to discuss the management of anaesthesia in a patient with morbid obesity. Case. Female, 26 years old, with intramural uterine myoma and morbid obesity, will undergo myomectomy per laparotomy with ASA II physical status, performed anaesthesia with general anaesthesia intubation technique using the anaesthetic agent Propofol 1-2.5 mg/kg titration until the patient falls asleep, fentanyl 1-2 mcg/kg, then the patient was intubated in a ramped position with sleep non-apnea. After it was confirmed that the ETT was entered, 30 mg of a muscle relaxant (atracurium) was added. The operation lasts 1 hour 30 minutes, with a bleeding 250 cc, hemodynamically stable. Conclusion. Morbid obesity has extraordinary implications for anaesthetic management. Various considerations for patients with morbid obesity are needed starting from the preoperative, intraoperative, to postoperative periods. Regional anaesthesia is preferred because the physiological function of unhealthy obese patients is impaired due to excess body weight. Selection of anaesthetic agent and calculation of drug dose is crucial to know because there is a change in the volume of distribution. The pharmacokinetics of most general anaesthetics are affected by the adipose tissue mass, produce a prolonged drug effect, and less predictable.

Erratum: Factors influencing patient falls in a private hospital group in the Cape Metropole of the Western Cape

No abstract available.

Design and Implementation of a Wearable Accelerometer-Based Motion/Tilt Sensing Internet of Things Module and Its Application to Bed Fall Prevention

Accelerometer-based motion sensing has been extensively applied to fall detection. However, such applications can only detect fall accidents; therefore, a system that can prevent fall accidents is desirable. Bed falls account for more than half of patient falls and are preceded by a clear warning indicator: the patient attempting to get out of bed. This study designed and implemented an Internet of Things module, namely, Bluetooth low-energy-enabled Accelerometer-based Sensing In a Chip-packaging (BASIC) module, with a tilt-sensing algorithm based on the patented low-complexity COordinate Rotation DIgital Computer (CORDIC)-based algorithm for tilt angle conversions. It is applied for detecting the postural changes (from lying down to sitting up) and to protect individuals at a high risk of bed falls by prompting caregivers to take preventive actions and assist individuals trying to get up. This module demonstrates how motion and tilt sensing can be applied to bed fall prevention. The module can be further miniaturized or integrated into a wearable device and commercialized in smart health-care applications for bed fall prevention in hospitals and homes.

E-learning as an effective method in the prevention of patient falls

Objectives Patient falls deteriorate patients’ functional condition and quality of life, and increase their treatment costs. E-learning is considered an effective way to gain knowledge and competencies for quality and safety in nursing practice. The aim of the study is to evaluate the effectiveness of an e-learning course for nurses in preventing in-patient falls. Methods The research design was mixed. In the first phase of the study, a five-year retrospective analysis of 2,280 in-patient falls was performed. Based on the analysis of risk factors for patient falls and group interviews with clinic managers an e-learning course was designed and completed by 250 nurses from five surgical and internal departments. The course’s effectiveness was evaluated based on the incidence of patient falls and the consequences of the falls before and after e-learning. Results At surgical departments, there was a statistically significant decrease in patient fall indices after the implementation of the e-learning course (from 4.4 to 2.6 falls per 1,000 patients; p=0.022). On the contrary, in internal departments, this index increased in the monitored period (from 19.0 to 26.9 falls per 1,000 patients; p=0.001). In all departments, there was a decrease in the incidence of patient injuries caused by falls after the implementation of the e-learning course; in internal medicine, this decrease was statistically significant (from 54.5% to 33.3%; p=0.014). Conclusions The study confirmed that e-learning forms of education for healthcare professionals have a positive effect in preventing patient falls.

Exploring the Environment behind In-Patient Falls and Their Relation to Hospital Overcrowdedness—A Register-Based Observational Study

(1) Background: Inpatient falls are a serious threat to patients’ safety and their extrinsic factors are, at present, insufficiently described. Additionally, hospital overcrowdedness is known for its malicious effects but its relation to the inpatient falls is currently underexplored. The aim of this study was to explore the distribution of falls and their extrinsic characteristics amongst a range of different clinics, and to explore the correlation and predictive ability of hospital overcrowding in relation to inpatient falls. (2) Methods: An observational, cross-sectional, registry-based study was conducted using retrospective data from an incidence registry of a hospital organization in Sweden during 2018. The registry provided data regarding the extrinsic factors of inpatient falls, including the clinics’ overcrowdedness. Simple descriptive statistics, correlation analysis and simple linear regression analysis were used. (3) Results: Twelve clinics were included. A total of 870 inpatient falls were registered during 2018. Overcrowdedness and total amount of falls were positively and very strongly correlated (r = 0.875, p < 0.001). Overcrowdedness was a significant predictor of the total amount of inpatient falls (p < 0.001, α = 0.05). (4) Conclusions: The characteristics regarding inpatient falls vary among the clinics. Inpatient overcrowding might have a significant role in the prevalence of inpatient falls, but further high-evidence-level studies are required.

Developing the Patient Falls Risk Report: A mixed methods study on sharing falls-related clinical information from home care with primary care providers

Background: The interRAI home care (interRAI-HC) instrument is valid, reliable, and capable of enhancing integration across health settings. However, its uptake has been met with criticism. If interRAI-HC information were shared with primary care providers in a useable, actionable, and context-appropriate manner, evidence suggests that its implementation could enhance care provision and integration between these providers. The objective of this study was to co-develop an information sharing tool with primary care providers for sharing clinical information from the interRAI-HC (named the Patient Falls Risk Report). Methods: This mixed-methods study, conducted from December 2019 to May 2020, employed qualitative and quantitative methods to develop and test the usability of the Patient Falls Risk Report. After recruiting primary care providers via snowball and maximum variation sampling, we employed semi-structured interviews in-person and over the telephone. The interview transcripts were analyzed through iterative thematic analysis and informed development of the report. Next, online surveys based on the System Usability Scale instrument were completed by a voluntary response sample of primary care providers and residents and descriptively analyzed to test the usability of the report.Results: Of the interview sample (n=9), we found that most believed that the Patient Falls Risk Report could support patient care by sharing relevant and actionable falls-related information. However, criticisms were identified including insufficient detail, lack of clarity, and limited support for shared care planning. After incorporating participants’ suggestions for improvement, a sample of primary care providers and primary care residents (n=27) determined that the report had excellent usability with an overall usability score of 83.4 (95% CI = 78.7, 88.2). Conclusions: By emphasizing usability and utility, and prioritizing the needs of end-users, sustainable interRAI-HC interventions can be developed and implemented to support care planning in primary care.

Examining Adverse Patient Outcomes in Nurses: The Role of Patient Acuity, Shift and Fatigue

This study identified key factors contributing to adverse patient outcomes (APOs) at a mid-western hospital. Understanding risk factors that contribute to increased nurse fatigue can provide solutions to reduce the impact that fatigue has on nurse performance and patient outcome. This study was comprised of two phases: 1) a database analysis of current data collected at a mid-western hospital, and 2) three focus groups to identify nurse perceptions pertaining to task demand and fatigue. The APOs analyzed in this study were medical administration errors (MAEs) and patient falls. A comparison of the data from both phases was then conducted to determine whether data reflected in the database correlated with nurse perceptions. This analysis documents significant results with respect to APOs in the following workload factors such as: hours worked, case mix index (CMI), shift, and nursing unit type.

Risk for Falls in Patients with Limb Amputations in the Clinical Institute for Rehabilitation and Orthopedic Aids of the University Hospital Centre Zagreb

Introduction. Patient falls are a significant clinical problem, as the fall can result in disability and, in some cases, death. The fall affects the patients’ quality of life, prolongs hospitalization, and increases the cost of treatment. Falls are the result of interaction between various factors. In the hospital setting, falls are considered adverse events. Aim. To determine the number of patients’ falls at the Clinical Institute for Rehabilitation and Orthopedic Aids of the University Hospital Centre Zagreb (UHC Zagreb) between September 1, 2019, and February 29, 2020. Methods. The data was extracted after the event from the Hospital Information System (Nursing records) and then processed. The study included 212 patients with limb amputations (both sexes) who were hospitalized in the Clinical Institute for Rehabilitation and Orthopedic Aids. Results. The results showed that patients with limb amputations have a risk for falls when doing rehabilitation for their primary diagnosis. Of the 212 patients admitted, 209 were at risk of falling according to the Morse Falls Scale, but of the total number of patients, only 2 fell. Conclusion. Patients with limb amputations have a higher risk of falls. The retrospective study shows that despite the increased risk of falls, the actual number of falls is very small. This shows that the medical staff are doing excellent work.